An Overall View of the Different Laboratory

Procedures Used in Conjunction with Lingual

Orthodontics
Laura Buso-Frost and Didier Fillion

The indirect bonding technique is an important component of lingual orth-

odontics. Many laboratory techniques are available for the indirect position-
ing and bonding of lingual brackets. In this article we aim to highlight the
advantages and disadvantages, as well as innovations and improvements,
that have emerged over time in each one of the main laboratory procedures
used for lingual orthodontics. (Semin Orthod 2006;12:203-210.) © 2006
Elsevier Inc. All rights reserved.

he indirect bonding laboratory procedure bonding technique the clinical time required to
T is often cited as major disincentive for orth-
odontists planning to start treating cases with
set up a full lingual case may be reduced by 50%.
The difficulty in access and lack of easy direct
the lingual technique. It is a procedure that visualization, not to mention the wide anatomi-
takes the bracket positioning control out of the cal variation of the lingual surfaces of the teeth,
orthodontist’s hands and, furthermore, adds an makes indirect bonding an essential procedure
extra cost to the case that the clinician may or for high quality lingual orthodontics.
may not pass on to the patient. Neither of these In this article we aim to highlight the advan-
features is particularly encouraging for the aspir- tages and disadvantages, as well as innovations
ing clinician. Nevertheless, it is an important and improvements, that have emerged over time
component of the lingual technique and cor- in each of the main laboratory procedures used
rectly managed it should be viewed not as a for lingual orthodontics.
disincentive but rather as a major incentive to
embarking on the lingual orthodontic route.
Over the past few years the indirect bonding Custom Lingual Appliance Setup
technique has evolved and become more widely Service (CLASS System)
accepted and practiced by orthodontists using
both labial and lingual techniques. A major ad- (Specialty Appliances Inc, 4905 Hammond In-
vantage associated with indirect bonding is the dustrial Dr, Cumming, GA 30041; www.
high degree of accuracy that can be achieved specialtyappliances.com)
with bracket positioning. A secondary advantage The CLASS system procedure begins with the
is the reduced chairside time required for the duplication of the malocclusion model to pro-
initial bonding appointment. Using the indirect duce a set-up model where the teeth have been
cut and correctly repositioned and aligned
(Fig 1). On this model the brackets are accu-
rately positioned. A flat metal plate helps posi-
The Windsor Centre for Advanced Dentistry, Windsor, England
and Department of Orthodontics, University de Paris V Paris, tioning of the anterior brackets and a separate
France. posterior device is used to position the posterior
Duralay, Reliance Dental Manufacturing Company, 5805 West brackets. The brackets are then transferred back
117th Place, PO Box 38, Worth, IL 60482, USA to the malocclusion model by using the cap
Address correspondence to Didier Fillion, DDS, 57a Wimpole technique, where a strip of acrylic covers the
Street, London W1G 8YP, UK.
© 2006 Elsevier Inc. All rights reserved. incisal edge of the tooth and overlaps onto the
1073-8746/06/1203-0$30.00/0 top of the bracket, making them one unit. This
doi:10.1053/j.sodo.2006.05.008 unit is then separated from the set-up and trans-

Seminars in Orthodontics, Vol 12, No 3 (September), 2006: pp 203-210 203

204 D. Fillion and L.B. Frost

1985.3 As the TARG machine does not take into

consideration the different thickness of the
teeth, many second order archwire bends must
be made routinely during treatment.

Bonding with Equal Specific Thickness

(BEST) System
(ELOS Laboratory, 145-147 Rue Louis Rou-
quier, 92300 Levallois, France; www.elos-
laboratory.com)
In 1986, Fillion2 developed a new system. He
realized that there was an important feature
Figure 1. Set-up models are used in many of the
missing from the original TARG machine—a
laboratory techniques (CLASS, TARG, KIS, HIRO,
and others). (Color version of figure is available on- device to measure the distance in the horizontal
line.) plane from the labial surface of the tooth to the
slot of the lingual bracket (Fig 3). He added a
precise measuring device to the original TARG
ferred to the malocclusion model. Advantages of machine to allow compensation for the different
the CLASS system include the visualization of thickness between the teeth (Fig 4). This equip-
the final occlusion on the articulated set-up ment was later called the Electronic TARG. Po-
model showing possible premature contacts and sitioning the bracket so as to allow for compen-
residual spaces that may occur following space sation for the different labiolingual thickness of
closure in extraction cases.1 The main drawback the teeth facilitated the use of straight wire prin-
of the CLASS system is the many steps required ciples for both anterior and posterior teeth, thus
before delivering the final product. From dupli- reducing the need for second and third order
cating the original malocclusion models to the bends during the treatment (Fig 5). The brack-
repositioning of the brackets back on the mal- ets are bonded directly on the malocclusion
occlusion model, many small errors may occur; model; no set-up model is required. From the
these become cumulative, resulting in a less- information collected during the bracket posi-
than-ideal bracket set-up where several compen- tioning (torque, angulation, height, and thick-
sating archwire bends become necessary during ness), a special computer software package was
treatment. developed to trace the ideal archwire for each
individual patient. This computer-generated
Torque Angulation Reference Guide
(TARG) System
(Ormco Sybron Dental Specialties Inc, 1717
West Collins Avenue, Orange, CA 92867; www.
ormco.com)
The TARG machine was launched by the
Ormco Society in 1984 as an important aid to
the laboratory technique.2 It allows the accurate
placement of the brackets at a precise distance
from the incisal and occlusal surfaces of the
teeth, as well as making it possible to prescribe
the torque and angulation for each tooth indi-
vidually (Fig 2). This creates a “virtual” set-up,
and the brackets can be bonded on the maloc-
Figure 2. The TARG machine has several blades,
clusion model, with each bracket having a spe- making it possible to prescribe the torque and angu-
cific resin-modified base. The TARG system was lation for each individual tooth. (Color version of
comprehensively described by Altounian in figure is available online.)
 Laboratory Procedures 205

Figure 3. The Electronic TARG has a precise measuring device that measures the distance (thickness) between
the labial surface of the tooth and the slot of the bracket. (Color version of figure is available online.)

archwire tracing was called DALI (dessin de The slot machine was designed by Thomas
l’arch linguale informatise) and its main advan- Creekmore for the placement of both conven-
tage is that there is no need to clinically coordi- tional and lingual brackets directly onto the mal-
nate upper and lower arches at the chair side, as occlusion model. The procedure consists of po-
the computer will have already done this proce- sitioning each tooth to a prescribed torque and
dure for the clinician (Fig 6). The new labora- angulation; the machine orientates the bracket
tory technique using the Electronic TARG and slot with the Andrews labial archwire plane (LA
the DALI program was called the BEST system.2 plane).4 The slot machine can be used for the
placement of brackets having either horizontal
or vertical access archwire slots.1 The fact that no
Slot Machine
model tooth set-up is required is a major advan-
(Ladent Centro de Ortodoncia y A.T.M. C, Mu- tage, but the difficulty in managing the many
seu 61o 1a, 08912 Badalona, Barcelona, Spain; pieces of the slot machine might be seen as a
www.centroladent.com) disadvantage.

Lingual Bracket Jig (LBJ)

(Silam Orthodontics Ltd, 19 Almong St, Ramat
Efal 52190, Israel)
The LBJ developed by Geron is the only sys-
tem that allows direct as well as indirect position-
ing of brackets (Fig 7). It consists of a set of six
jigs for the anterior maxillary teeth, one univer-
sal jig for the posterior teeth, and a special ruler.
The jigs transfer the Andrews labial bracket pre-
scription to the lingual surface. An occlusal stop
measures the height of the bracket from the
incisal edge. The correct positioning of the
Figure 4. Thickness difference between different
teeth need to be compensated for during bracket bracket provides torque, tip, rotation, and in-out
positioning to allow working with a straighter arch compensation. It can be used with the new
wire. (Color version of figure is available online.) Scuzzo-Takemoto brackets (STb) as well as with
206 D. Fillion and L.B. Frost

Figure 5. Compensating for in-out tooth thickness differences make a good final result achievable with
reasonably straight wires. (Color version of figure is available online.)

any horizontal slot brackets. Its main disadvan- The TOP system uses a set-up technique sim-
tage is the limited number of prescription jigs ilar to that used for the BEST system, allowing
available.5 the brackets to be placed directly on the maloc-
clusion model.6 The technique uses the TARG
Professional, which has a bracket holder for twin
Transfer Optimized Positioning
brackets and tubes in addition to the horizontal
(TOP/INCOGNITO i BRACES system)
and vertical measuring systems first described by
(T.O.P. Service f°r Lingualtechnik GmbH, Lin- Fillion. The target set-up is used to find the
denstr 42, 49152 Bad Essen, Germany; top@ optimal height for the brackets. Once the height
lingualtechnik.de) is determined the brackets are positioned di-

Figure 6. The DALI software coordinates upper and lower arch designs, making it possible to have the wires
constructed in advance, thus reducing chairside time. (Color version of figure is available online.)
 Laboratory Procedures 207

archwires are used and they are fully engaged

into the bracket slot.

Korean Indirect Bonding Set-up (KIS)

System
(IV Tech 4F Nassa B/B 581 Shinsa-Dong, Kang-
nam-Gu, Seoul, Korea 135-892; www.invisi-
tech.com)
The KIS system was developed by members of
the Korean Society of Lingual Orthodontics
(KSLO) and uses a bracket-positioning machine
that allows the positioning of all brackets at once
Figure 7. Lingual bracket jig; can be used indirectly (Fig 9). Once again it is necessary to create a
on the malocclusion model or for direct bonding in set-up model; however, the set-up is created with
the mouth. (Color version of figure is available on- the help of a special set-up model gauge for
line.) increased precision.8 This system has several ad-
vantages; it is a very precise system that places
rectly on the malocclusion model, as closely as the bracket accurately and eliminates the need
possible to the lingual surface of the teeth with- for any bracket repositioning during treatment.
out in-out compensation for labiolingual thick- It allows for bracket height differences between
ness differences. Unlike other techniques, there anterior and posterior teeth, which facilitates
are no thick resin bases for compensation of the intrusion of anterior teeth. By minimizing
thickness differences; these differences need to the resin thickness between the bracket base and
be compensated for by archwire bending. The the lingual surface of the tooth, it facilitates the
archwires sequence for each case is produced incorporation of root torque. It is simpler and
automatically by a computer-controlled bending faster compared with the systems that use a rigid
robot (Orthomate lingual module)7 (OrthoTel, arch to hold the bracket on the set-up model.
Berlin, Germany/Dallas, TX). Most of the work Overall, its accuracy assists the clinician in attain-
is delegated to laboratory staff, thus reducing ing a high standard of treatment that we contin-
chairside time. This technique also allows for the ually seek.
bracket and base to be custom cast in gold as
one unit for each individual tooth (Incognito i
Hiro System9
BRACES system). The fit to the palatal surface of
each tooth is extremely accurate and the pre- Two laboratory techniques that do not require
scription for each bracket should be fully ex- special equipment are the Hiro system9 and the
pressed for each tooth, provided the correct Convertible Resin Core system.9 The Hiro sys-

Figure 8. HIRO system; the transfer trays are made individually and transferred directly from the set-up model
to the mouth. (Color version of figure is available online.)
208 D. Fillion and L.B. Frost

Hybrid Core System11

This is not so much a bracket-positioning system
but rather a bracket-transfer system. The Hybrid
Core system developed by Matsuno combines
the favorable properties of silicone and compos-
ite resin in the construction of its indirect trans-
fer tray.10 Silicone covers the bracket and this in
turn is covered by composite resin. This combi-
nation allows for stable positioning of the trans-
fer tray within the mouth, followed by easy re-
moval of the silicone component from the
bonded bracket.

Figure 9. KIS system; all brackets are positioned at Simplified Technique

the same time. (Color version of figure is available
online.) (Ormco Corporation, 1332 South Lone Hill Ave,
Fairview, NJ 07022)
The Simplified Technique is associated with the
tem was created by Toshiaki Hiro and improved
development of the new STb brackets (Fig 10).
by Kyoto Takemoto and Giuseppe Scuzzo. It still
The brackets are positioned directly on the maloc-
relies on the preparation of a set-up model
clusion model by using a bracket placement plier
where the teeth are sectioned and correctly
or simple tweezers. The anterior brackets should
aligned. The brackets are positioned and placed
be at 1.5 to 2.0 mm from the incisal edge of the
on the set-up model with the help of a full-sized
tooth to the edge of the bonding pad— canines at
rigid rectangular archwire (0.018 ⫻ 0.025
2.5 to 3.0 mm. They should be orientated correctly
inches). Advantages of this technique are its sim-
with the long axis of the tooth. The posterior
plicity and lower cost compared to the previous
brackets are positioned at the center of the crown
ones. The transfer trays for each bracket are
by using a glue gun (sourced at a hobby or do-it-
made individually and transferred directly from
yourself shop) to create an individual transfer tray
the set-up model to the mouth (Fig 8). Chairside
for each tooth.
time for the initial bonding appointment is
The laboratory time and cost is minimal.
longer, as each transfer tray has to be positioned
Once the bonding is completed, the transfer tray
and bonded individually. The transfer trays are
is fractured off each bracket or the patient is
damaged following the bonding procedure, and
asked to rinse with a cup of hot water to soften
if at any stage brackets fail and need to be re-
bonded, new transfer trays must be made with
reference to the original set-up model.9

Convertible Resin Core System10

The Convertible Resin Core system uses hard
resin (Duralay; Reliance Dental Manufacturing
Company, 5805 West 117th Place, PO Box 38,
Worth, IL 60482) to prepare the individual
transfer trays and an elastomeric ligature to hold
the tray and bracket together. This allows accu-
rate repositioning of the bracket within the resin
core and the trays can be reused in cases of
bracket failure. The use of unitary trays makes
Figure 10. STb brackets can be positioned directly
the initial bonding session longer and the tech- onto the malocclusion model at 1.5 to 2.0 mm from
nique still relies on a set-up model to position the incisal edge of the anterior teeth. (Color version
the brackets.10 of figure is available online.)
 Laboratory Procedures 209

the glue. If it is necessary to rebond a bracket, a tion is sent back to the laboratory via the
new transfer tray must be made from the origi- Internet and a computer software program
nal model. As this technique does not compen- will design the transfer trays. A rapid proto-
sate for variations in tooth thickness, compensat- type (RP) machine will build the transfer trays
ing bends must be added to the archwire during in resin. A technician will then position the
the treatment. brackets in the transfer trays and add the resin
pad on the back of the brackets to finish the
Orapix System process. The main concept behind this tech-
nique is to make use of the precise bracket
(Korea Computer Information Co, Ltd, 302 My- positioning produced by the computer soft-
oungin Building, 234-27 Nohyun-dong, Kang- ware as opposed to using a technique that is
nomi-gu, Korea; www.orapix.com) dependent on human hands and eyes, as is the
The newest lingual orthodontic laboratory case for most other techniques.
technique is the Orapix system, which is still in
its final phase of refinement. A scanner will
scan a patient’s model and create a three-
Conclusion
dimensional (3D) data file. The orthodontist
will receive the 3D data file of the patient and In this overview of the different laboratory pro-
a 3-Txer software package via the Internet. cedures used in conjunction with lingual orth-
With the 3-Txer software the orthodontist will odontics, we have tried to present the different
visualize a 3D model and will be able to create features and, where possible, their advantages
his own virtual set-up on his computer for that and disadvantages. The variety of systems avail-
particular patient. The orthodontist will de- able may be confusing to the uninitiated lingual
cide on the required angulation, torque, curve operator. We would recommend that the aspir-
of the arch, and any other adjustments of the ing clinician consult with a reputable orthodon-
occlusion (Fig 11). All this will be easily visu- tic laboratory and discuss the different options
alized on the computer screen. The informa- that they have available. With the availability of

Figure 11. Orapix system; the clinician will receive the patient’s data via the Internet and decide on the
adequate angulation, torque, arch curve, and occlusion details on the clinician’s computer screen. The
information is sent back to the laboratory via the Internet. (Color version of figure is available online.)
210 D. Fillion and L.B. Frost

the Internet and overnight international deliv- 4. Echarri P: Procedimento para el posicionamento de
eries, it is feasible to use the services of labora- brackets en Ortodoncia lingual. (parte I). Ortod Clin
May-August, 1-2, 1998
tories far removed from clinician’s immediate 5. Geron S: The lingual bracket jig. J Clin Orthod 33:457-
environment. As a further option the orthodon- 463, 1999
tist may well consider setting up a simple case 6. Wiechman D: Lingual Orthodontics (part 1): labora-
within an in-house laboratory. tory procedure. J Orofac Orthop 60:371-379, 1999
Whichever system is chosen, only with prac- 7. Weichmann D: Lingual Orthodontics (part 2): arch wire
fabrication. J Orofac Orthop 60:416-426, 1999
tice will the clinician become more familiar and 8. Geron S, Romano R: Bracket positioning in lingual orth-
probably more selective. odontics— critical review of different techniques. Ko-
rean J Clin Orthod 2:39-44, 2003
9. Scuzzo G, Takemoto K: Hiro System Laboratory Pro-
cedure, in Scuzzo G, Takemoto K (eds): Invisible orth-
References odontics: current concepts and solutions in lingual
1. Echarri P: Tecnica de posicionamento de brackets orthodontics. Germany, Quintessense 39-44, 2003
linguales Class System. Rev Iberoam Ortod 16:1-17, 10. Kim T, Bae G, Cho J: New indirect bonding method in
1997 lingual orthodontics: convertible resin core system.
2. Fillion D: Orthodontie Linguale: Systemes de Position- J Clin Orthod 34:348-350, 2000
nement des Attaches du Laboratoire. Orthod Fr 60:695- 11. Matsuno I, Okuda S, Nodera Y: The hybrid core sys-
704, 1989 tem for indirect bonding. J Clin Orthod 37:160-161,
3. Altounian G: Le TARG. Inf Dent 22:2225-2234, 1985 2003